#217 Diabetes Pro Tip: Pre Bolus

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello and welcome to the fourth installment of my series entitled diabetes pro tip. In this episode, we talked about something so important it gets its own episode, and what could be that important Pre-Bolus thing. Today I'll be joined again by Jennifer Smith. Jennifer has been living with Type One Diabetes since she was a child. She also holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. Jenny is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitors. And I love the way she thinks about type one diabetes. If you'd like to get one on one coaching with Jenny, you can go to integrated diabetes.com. To find out more. Before we get started, I'd like to thank the sponsors of the Juicebox Podcast. Today we're going to be talking about Dexcom on the pod and dancing for diabetes, you can find out more about the sponsors and about Jenny, in the shownotes of your podcast app or at Juicebox podcast.com.

Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before becoming bold with insulin or making any changes to your health care plan. Now let's talk about the most important of important things, making sure your insulin is well timed with your meals.

In the episode about insulin, I told you that that my nurse practitioner CDA told us that fear of insulin was the biggest sticking point for people making good decisions with their diabetes, right. And after I got past my fear of insulin, the next hurdle I had to get past was Pre-Bolus. And I am now years and years later at a time where I will tell you that if you do not Pre-Bolus a meal, the likelihood of success is near zero. And if you have success without Pre-Bolus, saying.

All that means is that you gave yourself too much insulin prior to that. And it's just catching up now. And so this is it. We're going to talk about Pre-Bolus. And we're going to talk about how about insulin action, right the action of the insulin and how to balance it against the impact of the carbs or your body function. So tell me, let's go over the part that people aren't going to find comforting at first, right, which is, the amount of time it takes insulin to begin working in a person varies person to person and insulin to insulin. Is that pretty fair to say?

Jennifer Smith, CDE 2:58
It's pretty fair to say yes. And insulin to insulin. I would definitely say most of the rapids on the market should be fairly similar. The rapid acting influence on the market and their time of action should be fairly similar now. person to person. Yeah, that may vary situation to situation as well, creation to situation, it may vary. But again, that's the learning part of it.

Scott Benner 3:27
Okay, so person, the person could end up meaning just your body chemistry could mean where your infusion set is, right, you know, or your injections, right? Absolutely, yeah, you're a person who gets stuck on, I always injected my belly in the same place, that spot might not be as reactive to the insulin as if you would just try a new spot. If I went to a new spot, it might work quicker than it has been in your old spot. Right? If you're wearing an infusion set, it could and we alluded to it before you could get better action from your insulin on day one than you do on day three or better on day two, then, you know, two hours after you've put it on, there's a lot of different variables. But we're speaking generally here to you, you'll apply them to your variables later. Now, if you've heard this podcast before, you'll know that I have alluded to how insulin works in a number of different ways. So I'm gonna give my kind of cartoony description of it, and then we're gonna let Jenny talk about it for real,

Jennifer Smith, CDE 4:24
or 2d might be better as

Scott Benner 4:25
we'll see. So here's how I pictured my head a couple of different ways. The first way is I think of a tug of war. And I imagine a rope with a with a flag hanging in the middle of it. And on one side of this tug of war rope is insulin. And on the other side is your carbs and your body function. It could be adrenaline, it could be fear, it could be anxiety, whatever it helps to drive your blood sugar up. That stuff's on one side of the rope. The insolence on the other side. Unlike a tug of war in a school yard, our goal is not for one side to win. Our goal is for them both to pull and pull and pull until they get it exhausted, they both go, I can't do this anymore, and they drop the rope and our flag still in the center. That flag represents the blood sugar. You start at when the impact of the carbs begins in my mind. So I'll explain a little more. If you let them both start pulling at the same time, the carbs are generally speaking going to gain power and momentum before the insulin begins to work. So now your rope is going towards a high blood sugar and you're starting to head up. Now suddenly, you're 50 points higher. And what if you started with 150 blood sugar, now you're at 200. And now these carbs have momentum, they have speed, they're pulling your blood sugar up. Now, all of a sudden, 15 2030 minutes later, the insolence like, Oh, no, wait, I have a job to do. I remember and it kind of comes online. But now it's pulling, it can overpower the the momentum that the carbs have created. Plus, you now have another hundred points of blood sugar to contend with. And all you have is the insulin that you counted your carbs for. So even if you counted your carbs perfectly, and realize that this meal is five units, once the momentum of the carbs is rocketing your blood sugar up, once you have a number that is higher than you started with those five units, are not even going to begin to cover what's happening, let alone the food that you've put in. But if you put the insulin in first, and let the insulin come online slowly and begin to pull down and create the momentum in the other way, then you flip the script. And now the carbs are fighting. So instead of having a fight at 180, blood sugar, you're having a fight at an 80 blood sugar. And instead of your blood sugar falling at 80, it's being the attempt is that it's now trying to be pulled up by the carbs. And that's how when you see people with a stable graph, that's how they're doing it. And so for me, in a perfect situation, for me, my daughter's blood sugar is diagonal down when I give her most foods. Mm hmm. There's differences, you know, food to food, situation to situation, but in a perfect world. To me, that's it, you want your insulin working, your blood sugar trending down, creating some momentum down, when you allow the carbs to begin to pull up. Now, you explain that in a technical way that sounds

Jennifer Smith, CDE 7:28
and in most in most settings, yes, that's 100% I mean, insulin, our rapid, I've always thought that rapid is such a misnomer, honestly, rapid indicates like now rapid is like, you know, click, click, click lights with design, it's working. And it's, you know, still education is take your insulin and start to eat. I mean, even from most endo offices, it's take your insulin and start to eat, it's going to be working very, very quickly. That's not the case. And anybody who has been taking insulin long enough, and you've seen the spikes, and you've seen the issue is despite counting your carbs as precisely and weighing them and everything, and you're still seeing these issues. It's the mismatch of insulin timing, it is so rapid take anywhere between about 15 to 30 minutes to really get that active peak, not peak, but that active phase where then when you start putting your carbs in. They will match as you said that carb digestion will start to match with the insulin, you'll get a nice gentle curve up. And it should then start to curve back down. There is a lot of there's a lot of education that also focuses on, as you mentioned, watching for that curve down, watching for the curve down to start so that you know the insulin is already moving thing. Yep.

Scott Benner 9:04
Yeah. And to give you some context, the person I spoke about in a previous episode, who was having trouble, told me but what am I gonna do, I'm gonna be scared. I said, Well try it a little bit this time, and then a little more next time and a little more next time and go forward. And, and so I always tell this story somewhere. And I think here's the right place to tell it prior to glucose sensing technology being a thing that anyone knew about, but prior to, you know, Dexcom, I was again in the office and the CD says to me, hey, you're going to get one of those Dexcom things and I thought, I don't know what that is, you know, and she starts telling me it's it's a continuous glucose monitor. And I'm like, I again, don't know. And then she tells me this simple story. There's a 17 year old boy in our practice, who loves candy, certain kinds of candy and he can't figure out how to bowl with it. So he gets a dexcom whatever the first one was, I don't even remember anymore. His whole goal was to eat this candy without a spike. So it goes out to the store. And he buys like little grab bags of these candies and a number of them enough for a week and every day starts on this experiment first day, just like you said, eats, gives himself as his insulin, just like he'd been told his whole life, blood sugar goes up to 20, something like that sits there forever. Eventually, he has to give himself more insulin to bring it back down again. Next day, he tries a little sooner, give himself a few minutes, 510 minutes gets a little less of a rise. So the next day, he goes even sooner. And then before you know it, it's a little sooner, a little more, and he starts adjusting it back and forth a little more, a little sooner, a little later, until one day, he eats the candy. And his blood sugar never moves. And she tells me that story. And I thought immediately Wow, that means it's possible. Yeah, that was the first time I thought I was like, if that kid can do it with candy. I can do it with anything. Like anything, right? And so yes, give me that CGM. Please. And I got it. And I and I started, you know, dispense with my fear. And I started learning about it. There were hiccups along the way, right? I've given her insulin, and she's gotten lower than I meant to for two when she's eating. But you know, once twice, I'll go back to this over and over again, when something goes wrong. It's not a mistake. It's a learning experience. It's data for next time, right? Right. So I put the insulin in, and she goes down to 70 and sits at 70. While she's eating. It's beautiful. You know, like, there she goes that and then and then then a spike. Even if I really messed up on the amount of insulin I used a spike takes you to 120. Right, right, right. It's not right. It's just, it's all about that timing and amount. And I repeated over and over again, that you all the things you and I are going to speak about all the things that people hear about on this podcast, if you want to know how to use your insulin, at its core, the very first step is timing and amount. If you get used the right amount at the wrong time, you can use the wrong amount at the right time, that it's too much if the right amount of insulin at the right time, you have to balance the action of the insulin against the impact of the carbs. If you do that, I don't want to say it's easy, because that's insulting to people. But let me just say I don't think about diabetes that much anymore. It's easier, it's much easier if you do that. It is easier. Absolutely. And it's a lot more.

Jennifer Smith, CDE 12:26
It gives you a lot more visual than to understand. Because it's not so much of an unknown well, gosh, I counted the carbs, I took the right amount of insulin and this is always happening to me. Why. And if you can start to put those pieces together, it's not a y anymore. It's like turning the light bulb on. Here's how I explain what Jenny just said.

Scott Benner 12:53
The dexcom g six continuous glucose monitor gives you a complete picture of your glucose showing you where it's going and how fast it's getting there. There can be nothing more important. The dexcom g six also eliminates finger sticks for calibration, diabetes treatment decisions, and diabetes management. It also has an automatic inserter. Like it just you know, you stick it on and you push the button and the next thing you know you're wearing it. Now you can use the dexcom receiver to get the information from your transmitter. But for those of you who enjoy using your cell phone, it works great with iPhone and Android as well. The last little thing about Dexcom isn't so little. How about the share and follow features also for Android and iPhone, your loved ones can follow your blood sugar anywhere in the world. And if you're the parent or a caregiver of someone with Type One Diabetes, you can be watching their blood sugar as well. You want to know what Arden's blood sugar is right now. It's 82 just glanced up and saw it just like that. Now my results are mine and yours may vary. But my daughter's a one C has been between 5.2 and 6.2. for over five solid years. The decisions we make about how to give my daughter insulin and when to give it to her come directly from the data that comes from the dexcom g six. And I don't know if you know this or not, but my daughter does not have one dietary restriction. Those numbers are accomplished through waffles, just as well as through salads, through burgers, just as well as through zucchini. It doesn't matter anything that impacts my daughter's blood sugar. That impact is shown to me by the dexcom g sex and then I make good decisions. You want to make some good decisions, go to dexcom.com forward slash juice box and get started today. That's the best decision you're ever gonna make. This is a short episode and I don't want you to have to have to add breaks. So hang on for me for one more second. Let's talk about Omnipod. This past week I visited the AMI pod headquarters in Massachusetts where they've just moved their production facility. It's about to go live and I got to tour the floor where you're on the pod You're going to be made from now on, right here in America, right in Massachusetts, I want you to know that what I witnessed in Massachusetts on that assembly line, it didn't just renew my excitement about on the pod, it shot me over the moon, the accomplishment of bringing a production like that into one facility, putting it under your roof, that showed me a real commitment to the people living with Type One Diabetes. Right? This isn't being made overseas somewhere or you know, a bunch of different factories. It's all right there at the Omnipod headquarters, and it's state of the art is absolutely stunning. This is a company who is behind you for the long haul. I believe that before but I believe it even more. Now, here's what you want to do, go to my omnipod.com Ford slash juicebox. Or click on the links in your show notes or Juicebox podcast.com. When you get there request a free experience kit. That's right, a pack a pod experience kit on the pod is gonna send you a pod that is an exact replica of the one you'll get when you start using the product for real, but this one's non functioning. And so it's safe to wear for you to try out, you'll be able to find out if you like it, where you want to wear it. And you'll notice how after you've had it on for a little while you don't even remember that it's there. Miami pod.com forward slash juice boxes links show notes at Juicebox podcast.com.

Last thing, don't forget dancing for diabetes that's dancing the number four diabetes.com. It's the little organization that does a ton of good for a lot of people living with type one, they're on Facebook and Instagram, and it dancing the number four diabetes.com check them out. Here's how I explain what Jenny just said. I think of it as this equation that it's a mathematical equation that doesn't have any math in it. I did this. That happened. So next time, I'll do more or less sooner, you know, a little less a little more, that kind of thing. And I always just I always just keep looking at it like that. I did this. And that happened. It's the idea of being in a fistfight. And you want to hit first because now you have caused an effect. Right? And if you and so now, you know, I've done something. And that's what happened next. Now I can make a good decision about what what I do next, instead of waiting for diabetes to do something to you. And then you're just covering up your face hoping not to get knocked out. Right? Like because you don't know what's happening. You don't know why it's happening, you have no context for what's going on. But when you make the first move, you can be sure that what happens next was impacted by what you did, I put insulin in 10 minutes before you ate 10 minutes before I ate. And my blood sugar went to 150. So the next time I'm going to try 15 minutes. And if it goes to 130 I might try 20 minutes. And you know, if I get low, then later I might say okay, I might need a little more a little less. Now here's where people always say, Well, how much Scott How long? You know, give me the time, give me the amount? That answer for me is always going to be I don't know, figure it out for yourself. Okay, you have to

Jennifer Smith, CDE 18:13
this is the starting place.

Scott Benner 18:15
Yes. This is

Jennifer Smith, CDE 18:15
where to start. This is how to start. You have to do your own. I mean, diabetes as a science experiment, it's a daily, I feel like every day you're almost given like this new petri dish. And you're told, keep the dots growing purple today. Okay, let's work on keeping the dots growing proponents of something green pops in. And then these like little horny pink things pop on, you're like, Ah, you know, but it is it's like, it's a science experiment that for the most part, when you figure out what does work, the timing around the most typical foods that you eat and whatnot, it takes a lot less thinking out of the equation.

Scott Benner 18:55
Yeah. And while this isn't about Pre-Bolus, and we'll come up later. But it's important for me to say because I think this is impactful when you really stop and think about your, your habits around food. They're pretty similar. Right? Right. So you know, you're not I always say like this, like, if you're a person who gets a pizza on a Friday night and has two slices. You don't suddenly next Friday have seven slices. You don't go from being a two slice person to a seven slice person, right? Like Yeah, and so, so you can start making these decisions about how much insulin and when. And you can make them based on historical knowledge about what's going yeah,

Jennifer Smith, CDE 19:33
I usually tell people as the Pre-Bolus piece you've got most people have about 20 to 25 foods that are the most common for you to eat regularly. Yeah, that's at least 80% of your control there at least. So if you can nail the Bolus timing around those and figure it out, for the most part, you know, variations in setting will happen. Whatever Ever Yeah, but for the most part, if you've figured that out, you're also much more likely to be able to figure out food that isn't your norm, because of the similarities to what you've chosen. And what you're usually eating,

Scott Benner 20:18
because you can stay flexible, I call it 60 fluid, right? So here's, here's where I'll tell people this, don't get mad. I don't count carbs. I actually think about it a little backwards from maybe how most of you think about it. I don't look at the food and say, you know, weigh it or measured and say, Okay, well, that's 25 carbs. And my pump says that, I get one unit for every 10. So that's two and a half units. In honesty, there is no accurate insulin to carb ratio set up in Arden's pump. We don't even I don't even pay attention to that. I look at a plate and I say to myself, that's seven units. I think that if she's gonna sit down and gorge herself on nachos and cheese, the last time that happened, it took 10 units. I think of it as insulin, not as carbs. And of course, that takes a little practice, right? It does, it does. And it is a little contingent on you having a CGM, I'm not gonna lie about that, right, because I start with a healthy Pre-Bolus. And healthy would mean in amount and time. And then I watch her CGM, and I don't really watch it, I have her tolerances set tightly enough that if she leaves that range, I find out about it. So as an example, if I were to give Arden something incredibly carb heavy, I might use a Temp Basal increase, and a Pre-Bolus to try to spread out the action of the insulin across this timeline where there's going to be these carbs, right? If I make a bolus, and 30 minutes after I do it, she's 121 30 diagonal up. I look at that line. And it tells me something based on my previous knowledge, it's that I say to myself, ooh, this I missed, like, this isn't enough insulin, and I will give her more I will bump it and nudge it back. It's not a ton more, it's enough to stop the arrows.

Jennifer Smith, CDE 22:16
Right? And the arrows are very important to bring up in this in this as well. Because if you are using a CGM does arrows do indicate a rate of change? And again, that's not something that most people realize. They don't understand that and not understand.

Scott Benner 22:33
Don't tell us that

Jennifer Smith, CDE 22:34
it's that they've not been told they've not been told, hey, these arrows tell you that you're increasing by 30 to 60 points in the next 30 minutes. Okay. If that's the case, and I know what my kind of correction factor is, or whatever, I can say, Okay, I'm going to need this much more insulin, because if I don't correct my rising 130 blood sugar in the next 30 minutes, I could be 30 to 60 points higher. I could be as high as 190. I don't want to be 190 I've obviously miscalculated someplace, I can throw in a bit more insulin to counter that expected and stabilize it. Yes.

Scott Benner 23:11
Yeah. It very much. Yeah, it very much is remembering to, like I guess the way I usually say it is that you have to trust that what you know is going to happen is going to happen. Right? Yeah. You see, and and i think that the least important aspect of what the Dexcom does is the number. It's the direction and the speed, direction and hundred percent.

Jennifer Smith, CDE 23:40
I wish more please say that, again, is the direction it's the trend, it is not

Scott Benner 23:46
just the number, the numbers nice, like don't get me wrong, it's a starting point. But you know, if you're 60 and stable, and you haven't had insulin for three hours, you have had food for three hours, well, maybe you could get away with like a Temp Basal decrease of 100% for a half an hour, maybe you'll rise to 90, right. But if you're 60 and you're falling well, then you don't have enough time because as we've now discussed over and over again, insulin doesn't begin working right away. Also temp basals are insulin. It's funny how people think of bolusing and bazel is different. But once you're on a pump, it's the same thing. You can't just turn your bazel off and it starts happening right away,

Jennifer Smith, CDE 24:26
takes about 60 minutes for circulating insulin level to be different.

Scott Benner 24:29
And I always write and I always try to think of it a little bit as like Arden's Pre-Bolus time like if Arden's Pre-Bolus time is 20 minutes, well then setting a Temp Basal is not really going to start working for at least 20 minutes plus, it's a fraction of the bazel rate if if you're getting a unit an hour, and I say to it, okay, let's double it. Let's double it to two units an hour. That impact of that doesn't begin for 20 minutes or so plus, it's not the whole unit extra. It's the it's the fraction of it. So right when we talk about bazel We'll get to that. But so Pre-Bolus thing is really just the idea of balancing, again, the action of the insulin against the impact of the carbs, giving yourself a chance, not letting the carbs wash you away. Because here's what happens when the carbs wash you away. Count your carbs exactly right, you put your insulin in, you spike up the 200. When that happens, that insulin was only for the food. It wasn't for the 200 blood sugar, and it wasn't for the momentum of the rise. And so when I see that, like, I guess an easier way to say this, when when I don't have time for Pre-Bolus and Pre-Bolus. And to me is never about the number, you can Pre-Bolus a 65 blood sugar, you know, you can Pre-Bolus at 90 blood sugar, because still no matter what, if you're stable at 65, the insulin you put in is not going to start working until it starts working. So you have and so don't get me wrong. If I see a 65 blood sugar and I and Arden needs 10 units for what she's eating. I don't put all 10 units in at a 65 I might do an extended bolus which we'll talk about an extended boluses. But I get some insulin moving, I make sure the insulin is on the winning side of this tug of war to start. But in a situation where I can't Pre-Bolus let's say I know the meal is five units, hundred percent certain it's five units. But for whatever reason life, let's call it I can't Pre-Bolus and ardens. You know, I'm going to start eating right now. I'll give her seven units. Mm hmm. Because I Bolus for the food, the five units for the food I knew. And I pre buy. And I'm Pre-Bolus seeing the rise, I know is coming. And the and the number I know is coming. So I'm already treating a high blood sugar that hasn't happened yet. Because I know it's going to happen. Because I didn't Pre-Bolus

Jennifer Smith, CDE 26:54
right. JOHN Walsh goes into detail about what you're doing in a little bit of a different way. He calls it super Bolus,

Scott Benner 27:01
I call it over bolusing.

Jennifer Smith, CDE 27:02
Yeah. And he calls it super Bolus in the way that you take that five units, let's say in your example, and let's say your bazel behind that meal for the next two hours is one unit an hour, you actually take your bazel running for the next two hours, and you add it into the Bolus for the meal and you take it all up front. And then to decrease the chance of being too low later. Because of so much upfront action and the blood sugar staying normal, you actually set a temporary basal decrease, he recommends starting with 100% because you've loaded that onto the front to avoid a low but on the back end. Some people find though that attempt B is 100% off is too much. They only need a 50% they still call the spike and prevent it. But in the back end, they're not having a low then. So similar kind of concept.

Scott Benner 27:58
Yeah, I consider that trading Bolus for Basal. So so you know, say 120 diagnol, up 3040 minutes after a meal and I go, Oh, geez, I gotta stop that arrow. How much do I Bolus to stop the arrow? I usually Bolus an hour's worth of a baby of basal insulin. That way, if the arrow stops, and I stay steady, and she doesn't go down, I say okay, well, obviously, I was just wrong on the initial amount. But in those situations where you push the button, you know the unit and a half goes in, and five seconds later the error goes from 120. to diagnose the flat you go, Oh, I didn't need that. Right Temp Basal off a half hour. All I've done is trade the Basal for the Bolus. Absolutely. Here's a good place to say this. And we'll say this in each of these little vignettes. Never suspend your bazel it's always temporary basals. When you suspend you're shutting your pump off when you shut your pump off. It does not.

Jennifer Smith, CDE 28:52
You have to remember to turn it back on. Yes,

Scott Benner 28:54
yep. It's always temporary, because you can set at Temp Basal for a half an hour, an hour, two hours, but at the end of that time, it was that it'll go back on and start delivering your Basal it's always temporary Basal is not not don't suspend your pump. Okay, so I think do you think we covered Pre-Bolus? there?

Jennifer Smith, CDE 29:11
I think that's pretty good. Good. Yeah, that's awesome.

Scott Benner 29:16
Don't forget that you can work with Jenny yourself. If you want just go to integrated diabetes.com to find out how. Let's also take a moment to thank our sponsors Dexcom on the pod and dancing for diabetes. There are links in the show notes of your podcast player app, or Juicebox podcast.com. But you can always go to dexcom.com forward slash juicebox. My omnipod.com forward slash juicebox or dancing the number four diabetes.com. I hope you're enjoying the pro tip series. This was Episode Four where we talked about Pre-Bolus. And don't forget that episode one is for those starting over or just being diagnosed. Episode Two was all about multiple daily injections. Episode Three. We talked all about insulin. today of course Pre-Bolus Singh. In the next episode, Temp Basal rates huge and important and then after that insulin pumping, they're designed to be listened to an order, trust me, listen to them in order. I have just a little bit of music left here. So let me thank everyone for the great reviews and ratings on iTunes. very much appreciated.

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#212 Diabetes Pro Tip: All About Insulin

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:09
Hello, welcome to the Juicebox Podcast. I'm your host, Scott Benner. This episode is the third in a series with CD Jenny Smith. If you haven't heard the first two, go back and find them. The first one is called diabetes pro tip newly diagnosed or starting over. The second is diabetes pro tip all about MDI. And this one, of course, diabetes, pro tip all about insulin. They're designed to be listened to in order. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before making any changes to your health care plan for becoming bold with insulin.

What is it about insulin that people need to understand at its core? And I'll start by telling you that it just a very simple story that that I was in my nurse practitioners office one day, you know, I like to say we're at the end. No, but honestly, I never see the end. Oh,

Jennifer Smith, CDE 1:13
right. It's always a nurse practitioner who is? Yeah, yeah. And most often they've got more time anyway. So that's a good gap. When people

Scott Benner 1:22
say who's your I know, I sometimes have to pause. I'm like, Huh, right.

Jennifer Smith, CDE 1:25
I don't really know.

Scott Benner 1:28
So this was a number of years ago back before I think I would quote unquote, say that I started to understand. And I would say that I've understood diabetes on a different plane for about the last five years or so. Okay, but the run up to understanding it was reaching out into the world and picking these little ideas and really wrapping my mind around them. And as much as I tried to understand bolusing, or understand, you know, the, the peaks and the valleys my daughter was seeing and all the problems we were having. It wasn't until the certified diabetes educator and my daughter's practice, answered a really simple question for me. I asked her if you had a magic wand, and you could change the way people do one thing around diabetes, but would it be and without hesitation, she said, I teach them not to be afraid of insulin. She said that would be the core step one. Nothing else matters if you're afraid of the insulin. And I took that to heart. So I guess let's start with why are people afraid of insulin? What do you think it is? I think

Jennifer Smith, CDE 2:40
the main reason is because the initial education includes so much about hypoglycemia. Insulin, I mean, insulin is one of the very, very few medications on the market, that doesn't have a tremendous amount, but really doesn't have any effect on anything else, you know, it's not going to cause your eyeballs to turn green or you know, your toenails to grow extra inches or anything funny, right? It's its side effect, let's call it is hypoglycemia, low blood sugar, if you don't understand how to use insulin, right, so that I mean, it's drilled into you, if you be careful of low blood sugar. This is how to treat low blood sugar. These are symptoms of low blood sugar, I mean, low blood sugar, low blood sugar, low blood sugar is drilled in. And so what are you going to get from that? I mean, if you're told every time you come to the stop sign that some car is gonna come and swipe you. You're not gonna like go into a stop sign either, are you?

Scott Benner 3:45
It's funny, I think of when you say that I thought of driving in my mind right away a little differently. I thought of when you first teach someone to drive, you teach them about the brakes. Right? Right. Right. So it's the it's the first thing you think, right? Like, even if they steer wrong, or anything, they're doing wrong, if they can stop, maybe they won't get hurt too badly. Right. And so it is really the same idea. I guess for doctors, they look at the giant picture that is type one diabetes. And they say what's, what's the thing where these people could run into a wall, they could use their insulin incorrectly cause a scary low a scary low might mean if you're an adult, loss of your own function, inability to stop that fall from continuing. Right, right. And then so let's talk about granularity for a second because I don't think we do this enough about diabetes. Insulin extracts sugar from your blood. Is that right? Yeah, yeah. And unlike my body, which knock on wood has a pancreas, it's working it my body knows when to stop. It gets me to a nice level, and it stops. manmade insulin is going to work until it's not there anymore, and work

Jennifer Smith, CDE 4:54
and work and work and work and it's going to work in an interaction setting with The food that it's meant to work with or the glucose that's in the in the bloodstream for it to work with now, there's too much insulin there, and there's not enough glucose for it to continue to work with. And it's still gotten a whole hour of action. Absolutely low blood sugar.

Scott Benner 5:14
Yeah, it's not going to cause a low blood sugar. Like you said, if there's impact of carbs impact of body function, then that's what the insulin is working against a minute, the carbs are going from your system or the adrenaline you had is gone. This insulin, if it is still there, if you've missed timed, it, is going to continue to work. So that we know what we are scared about. Let's be more more honest about it. I'm gonna test myself and you'll tell me if I'm wrong. Sugar is the energy that our brain works off of. It's the the gas for our brain, right?

Jennifer Smith, CDE 5:51
It is. Yeah.

Scott Benner 5:52
And if there's not enough sugar in our blood, our brain shuts off like a light switch. Is that correct?

Jennifer Smith, CDE 5:59
in an easy way of saying it? Yes. If our brain is not getting the that sugar? Yes, we that's why all of those strange symptoms come about with low blood sugar, your brain is being deprived of the food it needs to function to think the right way. Yes.

Scott Benner 6:19
Let's just throw it on the table, what everyone's really afraid of right. Nobody wants to die when they're sleeping. That's what everybody's concerned about. I don't want to say that that's not an issue, because if it happens to one person, it's an issue. I would say that I do think of it again, like driving like I, I think driving is incredibly dangerous. But I do it every day. If I happen to have an accident one day where I'm killed, I will not be thrilled about that, as I see the telephone pole coming for me, right. But I think that's maybe the cost of doing business for being alive, I have to get around, I have to travel. Right? I think the same thing about diabetes, you need to use the insulin in an effective way to make your life healthy, longer, happier, you know, all that stuff. So you have to learn how to do this. And then the rest of it just like driving, you throw it away, you're like, Okay, I'm going out there, and I'm going to do my best. And the first thing that happens is people get dizzy, confused, they're easily agitated. But then as your blood sugar continues to drop, you lose the ability to what, like what happens as you continue to get lower.

Jennifer Smith, CDE 7:21
And again, this is where symptoms are different for everybody. But truly what can what really continues to happen is the loss of the right way of thinking you it just continues to decline. And if it gets far enough, you could lose consciousness, you know, you could certainly no longer be awake, doesn't mean doesn't mean daft, but it does mean that you could certainly pass out, um, from a low blood sugar. Yeah, you'll

Scott Benner 7:51
hear it adults sometimes say they knew it was coming, they consumed a ton of food, then wake up on the floor, because then the food gets in and it turns things around for them. Wow. So I'm gonna I've said this before, but, you know, for context in this episode. Prior to technology, I mean, honestly, back when we were needles and little tiny like I've said before, like a diabetes bubble gum water, right. I have caused Arden to have two seizures. One right after she was diagnosed, she was only maybe a few months into it. And I had this grand idea that I had figured the whole thing out, which probably meant she was honeymooning. Right, right. And we go to the mall one day to pick up some stuff real quickly. My wife's going on a trip and we need I think another bag or something. Everybody gets hungry while we're running through the mall. And here's this like, mall Chinese food. And I thought this does no big deal, right? I'll just count the carbs and I'll shoot the insulin and she'll eat the food and she ate and it was good. And she was little two years old. She ate a little bit of food. I gave her No, not a lot of insulin for a 20 pound person. Right, bought the bag went home. She fell asleep in the car later in her crib. My wife and I are helping her. I'm getting her packed up for what she's doing. And then I hear what sounds like a wild animal in my house. grunting and snorting and like like that. And I go into the room and there's my daughter. She is having a seizure in her crib. And so I pick her up and I don't know what to do. I mean, I know the doctor told us about glucagon. But for the life of me in that moment, I couldn't. I couldn't hold my hand. Still, I couldn't reconstitute it. It was a disaster. While she's on the floor, and my then seven year old son is dialing 911 for us My wife is rubbing glucose gel in her cheeks. And as I'm fumbling with the glucagon and really messing it up, Arden is blind. If you touch her she overreacts in a way like she thinks she's being shot like right like he or she is grunting and incoherent and then it just ended. Like when the glucose gel was And she came back and the police came into the house and the rescue squad and we went to the hospital and now I look back, we didn't even have to go to the hospital. Like the hospital was nothing. By the time we got there, her blood sugar was back up, and she was fine in this whole thing.

Jennifer Smith, CDE 10:14
But it's scary. I mean, just, you know, you're saying it. Yeah. You know, I mean, and I talk with and work with so many parents with little, little little, you know, and it is, it's, it's scary when it's when it's your child, and it's not even you. You know, the worst thing now can tell the scary story to tell what I think is the funny story.

Scott Benner 10:39
Yeah, so a year and a half later, we're at Disney for the first time. So our first time outside in the heat. On a big day with diabetes like diabetes, the whole day is going great. Again, no CGM still using needles. end of the night we're walking back to the hotel and coming at us is a vendor holding these giant popsicles. Remember looking up and seeing them and thinking we're like 200 yards from the hotel, like make a left turn, what are you doing, you know, but it's hot out and it's late. And my kids see those and they're like, Can we have them? And I thought, sure, I'm gonna do what the doctor told me to do. I counted the carbs, I gave her the insulin. And of course, it turns out I know now, you know, I could have just let her eat that popsicle. It would have been It was a fast acting car but might have hit her spider a little bit and gone away. I didn't eat any of it. But there we are back in the hotel room. Packing again, always packing with seizures in my house. And so we're packing because we're leaving the next day. She's laying in a bed often another room sound asleep, and I hear that noise again. And this time instead of being confused and thrown off, I say to my wife Arden's having a seizure. Now remember, it's been a year and a half since it happened before. And my wife runs and grabs Arden brings her back, she's holding her and I have the glucose gel and this squeezy tube. Now the gel we owned, you had to screw the top off of them pull the foil thing often, I guess CalFresh

Unknown Speaker 12:08
and then you can use as a gel spoil.

Scott Benner 12:12
Cuz you never cut you know, because honestly now in the of course the ensuing 12 years later, we've never Arden's never had a seizure since then, but right, so I unscrew the cap, and I go to squirt out the gel, and I don't pull off the foil cover. And I squeeze it so hard with so much enthusiasm that a pinhole breaks on the opposite side of the thing. And I'm squeezing and I'm like what's going on and then I look up and on the ceiling of the hotel room is a kaleidoscope of gel, I'm shooting all over the ceiling. So I don't even pause I flipped the thing upside down. And now I just scored it from the pinhole into Arden's mouth, we rubbed around, she wakes up, we put you know, get everything straight, put her back to bed, we were traveling with my brother, when it was all over and to say that it might have been a four minute experience, right? When it was all over, I look in the corner and my brother is cowering in the corner, just with a look on his face. Like he can't believe what he just saw. And my wife and I look up and see the gel on the ceiling, we crack up laughing, wipe off the ceiling, clean it up and go back to packing

Jennifer Smith, CDE 13:14
experience is a good example of the fear.

Scott Benner 13:18
That's exactly right. Because no matter how much I explained it to him, and I said, Look, you know, I don't want to call this the cost of doing business. But we've never been in this situation before we're completely blind. We don't know what our blood sugar's doing. I think the point is this. My point is this. I don't think my point is this. I know my point is this. I don't want to have a seizure. But in Geez, two to 15. In 13 years of having type one diabetes, it's happened twice. It was both when she was tiny. It was both when I didn't know what I was doing. And it was well before the technology that exists now.

Jennifer Smith, CDE 13:52
And before experience of walking around. I mean, in this example, walking around a park all day and not really knowing, hey, she could probably get away with having this little bit of extra sugar, she'll climb, she'll come back down, the exercise is going to hit all night long. She doesn't need insulin, you didn't know that

Scott Benner 14:09
no idea. And now I do. And now Arden can go play softball for nine hours on 105 degree day and she doesn't get low at the end of the day. Because now I know what I'm doing. But I fear that exists exists for that reason. And so I don't know how comfortable you are talking about this because I haven't asked you ahead of time, but how real and this then we'll get off the fear and we'll move on to other stuff about insulin, but how real is the concern that I'm going to go to bed one night and not wake up the next

Jennifer Smith, CDE 14:41
day? I would say that the concern? It's a real concern. 100 Absolutely. It is. Is it a concern that it could happen? wildly out of the blue with and I bring this up With the technology we have today, I would say is that piece is, it's not going to be as common. And it's not because we have alarms and things that set now is technology always perfect. No mean, we can get alarms and alerts for blood sugars that are ultra low or look like they've dropped off the map and you do a finger stick, and it's that the sensor was not right, you know, it was a, you know, a kind of a compression low, or you could have a low alert, and you could actually be lower than the low alert already, right. However, the fear of going to bed and not waking up. While I would believe that it's there, for 90% of people with diabetes, the other percent, maybe don't even think about it or know that it's a potential again, education piece there. But I think that there is the knowing about insulin and action going into that time of the night. I think that's a piece that can really help to prevent that from happening.

Scott Benner 16:10
As we move forward, you'll hear me say a number of times that I think that highs cause lows, because highs create situations where you have unbalanced insulin. And and eventually, like we talked about earlier, body function, blood sugar will will be pushed away by the insolence they're leaving more insulin behind. And there are a lot of times that people will say to me, you know, I get low at 2am. Or, you know, it always happens. And I think well, I don't know that you get low at 2am. It's very possible it's something's happening hours before or you're using insulin hours before. And it's and this is what the residual of that. Right. And so when you use insulin more thoughtfully, I guess is the word. Right? Yeah, that's a great word. You don't have as much of it laying around later in your body that has nothing to do except for to make you low. Correct. And I'm hoping that we get to that as we speak, you've addressed fear and insulin, it's a real thing. It exists for most people. There's good reasons why you should be afraid. But how do we stop people from being afraid?

Jennifer Smith, CDE 17:16
But I think the fear too, and just to kind of clarify there, it's okay to be afraid. But it's also really important that you do something to understand and, and be able to get rid of the fear. It will be there it is certainly, but it's important to learn how to not worry so much with the fear. Let

Scott Benner 17:41
it overtake you. I think of it let it overtake you. Like they tell you with fire when you're three years old? Yes. You have to respect fire. But you can't be afraid of it. Right? Yeah, be afraid of it. Exactly. Yeah. And that that's what I do. I it was the first leap that I made that brought me to the place where I am now. And I think that I think that no matter what tools you give people, if they're afraid to use them to kind of, it's never going to work out quite right. And it's always going to become unbalanced, they're always going to end up in a situation where they go see, look, this is diabetes is unpredictable. And and this is always going to happen and then you know, and that that's that so Okay, so all right. So what's the first step to not being afraid? It's got to be understanding how to use the insulin, right? Absolutely. Okay. All right. So we're gonna get

Jennifer Smith, CDE 18:31
100% 100% Yeah,

Scott Benner 18:33
so let's understand a couple of things. First, that the insulin can do the cause issues for people and one, right people say, I started using insulin, and I started gaining weight. Okay, now, very recently, I had an interview with Chris Rutan, where Chris said, That's not as really nearly as much about the insulin is, as it is about calories. And that was his take on it. Like if you eat extra calories, you're going to gain weight. And that a lot of times we have low blood sugars that we treat with food, but we don't think of that food as we think of it as as necessary because it is not because you're alone, right. But what is the act what is the what is the the technical reason why people see weight gain with insulin. Elizabeth forest was diagnosed with Type One Diabetes. At 10 years old. Then a student in Holly recurs dance class, Elizabeth decide to start a nonprofit organization. Now this wasn't something that she had considered previously, but either was being diagnosed with type one. But after her diagnosis, she was driven to not let diabetes negatively impact her life. And she was inspired to start dancing for diabetes. She did this as a way to bring attention to the stories of the 1.2 5 million Americans who are living everyday with type one and to offer support to those who have been diagnosed and on top of all that she's raising funds to find a cure. started as a community fundraiser organized by a middle school student and a small group of trusted advisors has blossomed into a full scale theatrical production involving hundreds of local dancers and community supporters. Dancing for diabetes has been impacting people through dance for almost 20 years. It has grown from a middle school auditorium to filling Orlando's Bob Carr theater, and is well considered one of Orlando's premier charity entertainment events of the year. I spoke last year at one of their events, and had such an amazing time that I'm going back again in 2019. Elizabeth doesn't have a ton of money to do advertising, but she wants to spread the word about dancing for diabetes, which is why you hear during some of our episodes, I just pop in and say the name really quickly. They're trying to build awareness for their organization, while building a better future for people with type one. So you've heard me say before, and I'm going to say it right here. good at dancing for diabetes.com that's dancing the number four diabetes.com check out what they're doing. It'll put a smile on your face, and maybe you'll decide to get involved. Real good foods believes in making delicious foods, high in protein, low in carbs that are made from real ingredients so you can feel the goodness. You'll never find weird sounding words on their ingredients labels, nor will you find processed grains, flours or other fillers. For example, instead of flour. Their Single Serve pizza crust is made from two ingredients. All natural chicken breast and parmesan cheese. Real good foods family sized cauliflower pizza crust is made from cauliflower, egg and cheese, and all of their foods are grain free, gluten free and use natural ingredients. That includes my wife's favorite enchiladas. The poppers that I love so much the chicken crust pizza Arden adores, and the cauliflower pizza that my mom can't get enough for being a listener of the Juicebox Podcast real good foods would like to offer you 20% off of your entire order. All you have to do with Checkout is use the offer code juice box. And as if that wasn't enough, they also have free two day shipping. Let's hold up some of real good foods products against popular competitors. Their Margarita cauliflower pizza has nine grams of carbs and 20 grams of protein. That other pizza that you know about has 37 grams of carbs, and only 12 grams of protein. Real good foods enchiladas has four grams of carbs 20 grams of protein, and that other one that you know about has 18 grams of carbs and nine protein. Now on to the poppers, there must be even somewhere right? Nope, not even close three grams of carbs for real good foods 29 for the competitor, and protein 22 to four, you can use the links in your show notes or Juicebox podcast.com for both dancing for diabetes and real good foods. And don't forget when you get to real good foods calm to use the offer code juicebox at checkout to save 20% Why do some people see weight gain with insulin?

Jennifer Smith, CDE 23:04
The easy answer there is that the insulin is being it's being mismanaged the dosing of it is being mismanaged and mismanaged Why? That takes in depth analysis of what's going on in the person's individual settings. Right? The and I work with a lot of people weight management wise, type one who I you know, I just I've gained weight or I've done this my blood sugar's are no better, but I've gained weight. Now, if the start with if you're running really consistently high blood sugars, you're actually eating out calories. you're peeing out glucose, because that's how your body is trying to get rid of the excess because there's not enough insulin there to bring it into your body and utilize it. So you may be maintaining a weight that you love. Your blood sugars are high that it's that healthy. On the second side, once you do reign in control, and you're now taking insulin to contain blood sugars, you may be gaining weight, because your body is now retaining some of those calories that were being lost before that you didn't realize, right? So that comes down to the point of understanding lifestyle and the management of insulin. And I bring up a really important piece that people don't, people don't realize. Insulin insulins job is a storage hormone. Insulin job is to pack the food into different places in the body. Right? It either packs it and moves it into your muscle cells or at packs it and moves it into fat. Right? It's usable or it's going to be hopefully used later. If there's too much of it, your body has to pack it away and utilize it later. So that's a that's a lifestyle piece. That's something to look at and say okay, where's my activity? level where it is my nutrition intake need to be is my insulin matching that, am I driving my glucose values too low and like you said, am I taking in too much because of low blood sugars that are consistently happening, and then you're adding more insulin to correct the high that follows and then you're dropping and you're adding food and you're correcting and add. So it becomes this vicious cycle of management, if you don't understand how insulin works. And in a body, I think a good point is that in a body without diabetes, insulin plays a very big role in weight management. And people without diabetes aren't injecting it, their pancreas is making it. So if they're themselves not managing lifestyle, they're having to produce a heck of a lot more insulin, to bring food out of their bloodstream for their body to maintain that normal blood sugar, the way that it's meant to do, they will likely gain weight too.

Scott Benner 25:58
So do me a favor and go over that cycle for a second. I take something in through my mouth that has carbohydrates in it, it goes into my stomach, my bag, my body begins to break it down. It basically those carbs are leached out that sugar, which is the you know, sugar is carbs a sugar comes out. And the insulin actually helps it go into my blood, right it or how does it

Jennifer Smith, CDE 26:24
insulin takes insulin, you know, we take it, we inject it or we pump it into our sub q tissue, it gets absorbed and dissipates that into our bloodstream is I guess the easiest way to say how it works. Insulin in the bloodstream then matches with the glucose from the food that we've eaten in whatever form you know, it could be rice, it could be celery, it could be an apple, whatever it is, sugar in the bloodstream, the insulin and combines with the glucose, they latch on together, and insulin is then the key to the door on the cells. With insulin, the doors open, the key unlocks the door on the cell, the glucose is allowed to enter the cell muscle cells then use it for energy. fat cells, pack it away. So

Scott Benner 27:16
that's how it works. And so with so without insulin, we go into DK, right and so and DK is what is it technically, but what what is it that's happening.

Jennifer Smith, CDE 27:29
So technically, with DK a, it's a significant deficit of insulin with high blood sugars. Right now there are cases of aka at more normal blood sugars. dk however, really is it's a deficit of insulin, meaning that your body is has no way to clear the glucose out of the bloodstream and move it into the places it needs to go. Now your body tries to compensate, like I mentioned before, with the weight management piece, if it tries to compensate, you get really, really thirsty with higher blood sugars. You take in more fluids your body up because you're drinking more, and your body is trying to flush a lot of that extra glucose out. And the only way it can if it can't do that forever, though, at a deficit of insulin. And so your body at the point of not having energy from glucose, it starts to break down fats and proteins. So ketones are produced with the breakdown of fat.

Scott Benner 28:31
Is that why? When I think back on Arden's diagnosis prior to it, she was ravenously hungry at the end, because she her body was starving, and it's telling her eat, we're starving, except the food went in. And then there was no insulin to move it into the cells where it was needed.

Jennifer Smith, CDE 28:49
Correct? Correct. I mean, I could have I remember, I mean, I was older than your daughter and I very, I very much remember the two weeks leading up, especially the week leading up to my diagnosis. I very much remember it. I mean, I at the lunch table in school with my friends. I was asking them for their milk. I was so thirsty and so hungry. And so they would they would get two milks, and they would bring one for me. I mean, I was consuming probably six of those little cartons of milk at every lunch and between classes in the hallway. I needed to get to the water fountain. I mean it was it was unbelievable. The unquenchable thirst and hunger.

Scott Benner 29:35
It really is. A threw me off for a second think of it. No, I won't get back on Arden's diagnosis in it. It just it always just makes me think like how do I not see her dying because she was, you know, no insulin in her body and she was withering away. And he looked back at a two

Jennifer Smith, CDE 29:51
year old it is. I think for kids, it's hard to because kids are hungry all the time. I mean, I've got a two year old and a six year old and man, like every hour, they're like I'm home. Hungry rabbits. I am hungry. Can I have that kids are hungry? Yeah. But it's a different it's a very different ravenous

Scott Benner 30:08
in that setting. Oh my god. Yeah. And so let me ask you something when a blood sugar starts to get low with a person who's being managed, but maybe they have there's their insolence on balance and they're getting lower. Arden will say she's hungry prior to a low blood sugar. And I always tell her Hey, if you feel hungry, first thing we should think about is is Are you hungry? Hungry? Or is your blood sugar getting lower about the same function right there?

Jennifer Smith, CDE 30:33
in a in a similar way, just in an opposite, you know, high blood sugars, you're hungry because your body is starving for the energy. Right? And it's not getting it. Low blood sugars. You're hungry because again, as we talked about, initially, your brain is being deprived. Okay? Your brain is saying, hey, you're hungry. There's not enough go grab something. There's not enough food here. I there's, there's too much of this insulin, it's calling. And sometimes even that precipitous drop in blood sugar that can happen. That's why overindulgence is there with low is I mean, you could literally go to the refrigerator and eat the whole roof. I mean, there there are people who have done that, or just the whole box of cereal. And they're like, okay, where's the next box? You know?

Scott Benner 31:24
It's Yeah, and it's commonly referred to as ether kitchen. Right? Yeah. So yeah. And, and, and so but when Arden was younger, and before sensor technology, and I was staring at her trying to figure out ways to understand where her blood sugar was. One of them was if she said she was hungry at what I thought were odd times of day. I thought, ooh, she might be low. And yeah, yeah, because the looking for the bags under their eyes was not working. I'll never forget, she's diagnosed and the nurse practitioner goes, you know, dark circles under the eyes could be signs of low blood sugar. And then she paused and she goes, or high blood sugar. And I was like, Wait, what? Was that gonna help me? And by the way, it never came to fruition. I spent No, I spent the first year for diagnosis, staring at her face looking for a sign of something wrong with their blood sugar, and it doesn't exist.

Jennifer Smith, CDE 32:13
I have never heard that before Scott in that, right. Yeah. Never heard that as a symptom of high.

Scott Benner 32:21
And it makes me think of the insanity of like when the Arden will say to me, like, you know, you'll be in the middle of a CGM changeover. And I'll say, hey, look, it's been an hour since we reset the CGM, or since we put it on whatever, why don't you go ahead and test let's just make sure we are very thing. Sure. And she'll say, I feel fine. And I always go, ironically, how you feel is not the best indication of what your blood sugar. So and so she still won't wrap it, she still doesn't wrap her head around that right away? If she feels Okay, then she thinks I'm okay. You know,

Jennifer Smith, CDE 32:54
well, and there are some children that have not quite even gotten to the point of realizing what the difference of body feeling is. Right. And if they've lived with diabetes long enough, they may not necessarily know what quote unquote, normal should feel like, right? They may not know that your diagnosis at two or three, they're not even realizing outside of like an ear ache that they're like screaming in pain, or they're pointing at their mouth, because they're two hertz or whatever it might be a kid that young are not in tune with

Scott Benner 33:35
other bodies supposed to feel

Jennifer Smith, CDE 33:36
and and associating it with Oh, I'm low Mommy, or I have a high blood sugar. And so then moving on through life, because they've had diabetes, from such an early age, when you do start to make those connections. It's very difficult to translate that then into, you know, older age.

Scott Benner 33:56
So I was it's funny, you brought that up, because this was gonna be my next question for you. So I just was interacting with somebody on Instagram, who, you know, found the podcast is bringing their blood sugar down, and they have a beautiful stable 85 blood sugar where they feel dizzy. Yeah, okay, now, so I'm talking to this woman, and she says, I'm going to ignore it. I know, it's not real. Like, I know, I'm not in trouble. So I'm just gonna power through maybe I'll give myself a little bit of carbs to you know, kind of help it a little bit, but I'm gonna power through it. Because I know my body's going to adjust to this. And I spoke to a different person who said that they got to that that nice, stable, good number and they stopped themselves from eating too much. But it still they had trouble doing it. So my question is, when you've spent such a long time with an elevated blood sugar, you know, thinking 180 was a great day, you know, or your 250 for six of the hours of the day and you finally get this all under control. You keep listening to these podcast episodes, and you get to A place where you're 85 and stable. When that first happens, you feel like you're low? What's the function of that, first of all, and tell people that it's going to get better, please?

Jennifer Smith, CDE 35:11
Yeah, I mean, the function of that is because your body is having to adjust the values that it hasn't seen as the norm, you know, an average of one at an average of 200, an average of 250. While it's high, you're you may feel normal at that, because you don't know what a normal value or a target value feels like. So as you start to notch things down, your body has to readjust to that new normal value, and it does take some time. So hovering, you know, now at even 110. For somebody who is averaging 200, they may feel low, that may very well feel low, it doesn't mean it needs treatment, is it's truly not a low value, but it does feel low. And so it's hard. It's hard to work through that. I

Scott Benner 36:10
don't know. But I can imagine. Yeah,

Jennifer Smith, CDE 36:12
yeah, yeah. So I, you know, I think as far as CGM, especially I think that's, that's good technology now that at least they can also see where things are going. I mean, if they're at 110, feeling low, and they're all where, all right, they're consistently still dropping very much, especially, you know, fingerstick wise, they might be lower than that. If they're on a trend, if they're hovering nice and stable, nice horizontal line at 110.

No need to treat that fight through it.

Scott Benner 36:39
How long does it I realized it'll be different for everybody. But what's the average amount of time before stable in range, blood sugar starts feeling normal,

Jennifer Smith, CDE 36:48
usually, at least a couple weeks. I mean, from starting, you know, the end, depending on timeframe of how long things were higher, it may take a couple of weeks for that to feel normal at those lower in target values. And again, stability there, and lacking this big jump up and down and whatnot, that makes a difference for resetting those symptoms in your body.

Scott Benner 37:16
Okay. I have one last question. And then we're gonna move on to something else. Can

Jennifer Smith, CDE 37:20
I show you my line right now? Yeah, Jerry.

Scott Benner 37:22
But look at you. Okay, I'm looking at at a Jenny six, our Dexcom line that looks like it's been right at 100 it might have dipped to was that Where's your low at 60 or 70? Below that? 7070 it hit 70 for a little while, maybe for about an hour, and then it banged up at 85. This is very, pretty good for you. Are we? Are we gonna? Okay, here we go. Let me compare. So Arden has one compression low in the last 12 hours. That isn't real. But other than that, let's see if you can see that.

Jennifer Smith, CDE 37:59
Very nice. Thank you. She's even averaging lower than me right now.

Scott Benner 38:03
And we as a new it's a new pump too. So I think you've got the best day. Yeah.

Jennifer Smith, CDE 38:09
I know those pod change days are like, it's almost like magic. Well, can be almost like magic.

Scott Benner 38:17
I actually got walked through walk somebody through how to pod change without a high. And we'll talk about that when we talk about pumping. But yeah, so here's my last question about insulin. Let's get I'm gonna go back to something scary for a second. But I think it's, well, I know how impactful it was for me. So back when I had to dispense with my fear of insulin, like we talked about at the beginning. How do you do that? Right? Like how do you make a leap like that for me, and it will probably be different for a lot of people. I started thinking more about long term health, I realized that the doctor was telling me to leave Arden's blood sugar high so that she wouldn't get low. We were trading today's health for tomorrow's right, like we won't die today. But we might not live a long healthy life either. And I thought that can't be okay. But I still couldn't make the leap. And finally, I thought about it in as technical and scientific way as my brain would allow. And what I what I came to, to think about was I actually spilled some sugar out on the table, and I looked at how kind of coarse and granular and sharp it was on its edges. And I thought well at its, you know, at its microscopic, like existence, it's probably still course in sharp like this. And our bodies are built to handle a certain amount of it flowing through our blood. But if you pack that blood with too much, that must be and this was me thinking my way through when people say I he died of a heart attack, you know, because of his diabetes or he went blind because of his diabetes or he couldn't feel his foot anymore. What that really means is that the sugar has basically sandblasted you from the inside, damaging right making damage to the inside of your veins and capillaries, all the places where bloods covered, right? If you have a heart attack, and they say it was because of diabetes, it's because the flesh in your heart got rubbed thin. And it

Jennifer Smith, CDE 40:10
burst. And I mean, and beyond that, beyond that are the other the other pieces of those complications, such as heart disease that come about, and most doctors don't teach this. And I think it you know, it may be a time thing it may be that they don't want to get the in depth piece of it. I think we

Scott Benner 40:35
should I think to bring up on day three of your dying day.

Jennifer Smith, CDE 40:38
Right, exactly. I am blasting yourself. I have a good and I wish that I could show this to everybody. But this is a tube full of a glucose solution. Do you see how slowly those little they're supposed to be particles of sugar are flowing through the bloodstream, yeah, sugar or nutrients, right, I like to refer to them as nutrients. Because this is the other piece to overall Long, long health with diabetes is, as you mentioned, glucose I love your rough part of that example, because it is high glucose levels cause your cause your blood to get sick, almost like molasses in winter, okay, which means that all of the nutrients, your bloodstream are also flowing very slowly to all the places in your body that need to get those wonderful, micro macronutrients. So healing and everything gets slowed. If your glucose levels stay as high as the the roughness of that sugar that you're talking about, or the high glucose values, it is it's very damaging to vessels almost creates like rust on a car, it creates damage on the inside of the vessels, your body tries to heal itself, it's a self healing machine, your body actually makes cholesterol. It's like a band aid. So even if you never eat cholesterol, again, your liver is meant to make cholesterol and cholesterol is like it does a lot of other things. But it is also a patch, the more damage, the more patch, you see how narrow my vessel is now getting the more and more patches, those vessels that narrow, that leads to high blood pressure, high blood pressure damages your kidneys, high blood pressure puts a lot of pressure on the vessels in your eyes. So it's a it's a snowball effect, with consistently maintained high blood sugars now have a 200 blood sugar because you decided to eat the whole, you know, Disney Princess cake or whatever. And then you bring that blood sugar down. That's, that's a different story than this consistent maintenance of high glucose. That's different.

Scott Benner 42:54
Yeah, right. I think that when people when I say that ardens A once has been between five and six to four or five years, I think people imagine a steady 85 blood sugar forever, which is not the case. Right? She spikes up just like everyone else, you know, if you're gonna if you're gonna eat with diabetes, and not have, you know, you know, not not have boiled it down to low carb or no carb or something like that, right? You're gonna miss sometimes I miss on boluses. You know, insulin pump sets aren't as effective on day three as they are in day one. There's reasons why right? Yeah. So it really is. It's not a perfection you're looking for it's a it's a fluidity of fluidity, it's a consistency to how you manage that's what keeps your eight, one clo, right, as you were describing cholesterol coming in and making patches on, you know, arteries or veins. And it it thinning, you know, that's what people would commonly think of as needing a stent in their heart, right? Like, eventually, it has to open up that space again. Right. So for me back to what I started to say, I got past the fear by saying to myself, I can't let my fear of something happening to art and today affect her entire life. Right? I just can't do that. And, and if that means she's gonna have something bad happened to her or my life's gonna be a little more hectic managing insulin, then that's got to be what it's got to be. right because the alternative is I put all this effort and heart and love into my daughter and at the end of my life when I'm 65 7080 years old, and I'm looking back at my 40 year old daughter and she's in incredibly poor health. I'm gonna think like, what was this all for? Like, you know what I mean? Like what I spend my whole life doing so I'd rather get in the game now and do the best I can let the chips fall where they may a little bit. Then just to ignore it. I can't I am not across that bridge when it comes to IT person. I find I find when you think about life like that. People have heard me talk about it on the show before you get a bill. The mail you can't afford it. And you know, you can't before you open up the envelope, just open it anyway. Right? Be an adult and go, I owe the electric company $400. Like, right?

Jennifer Smith, CDE 45:09
No, that's not going to be better tomorrow, it's gonna be the same bill. Absolutely.

Scott Benner 45:13
It's the same idea with your blood sugar. Like, don't ignore it. Don't say to yourself, that's okay. I'll deal with it later, because later is going to be worse. Now Sox laters worse. So, get in the game, do it. Now.

Jennifer Smith, CDE 45:27
I've always thought about myself, personally, I've always thought about all the things that I am able to do be, because I choose to manage because I have chosen to understand how to manage. I mean, I, I've done a lot of awesome things. I've had two kids, I, you know, I want to see those kids grow up, I want to be around with them. And that, that is the biggest thing to look out to future wise. And remember every day

Scott Benner 46:01
it is, and that's why you and I are doing this like series inside of a it's a it's a series of podcast episodes inside of a podcast. Right? Right. It's because somebody is going to hear that and think, yeah, that's nice, buddy. But I don't know how to keep my kids blood sugar at 70 and blah, blah. But I'm telling you, we're going to talk about how to do that in a way where you don't have to, when you hear the idea of keeping your blood sugar stable to lower number, it doesn't make you think, well, that's impossible. We're, we're going to talk about the tools that make it possible. And I'll leave this episode with this thought. Three nights ago, a man in his 40s I saw him on Facebook, and he was basically begging people, he was at the end of his rope. And he had had diabetes for a long time. And it was just not going well. And people are all jumping in giving them giving him their best piece of advice. And I always think the same thing. When I see people on social media. I'm like, wow, that's valuable. But how do you make sense of it, you know, then somebody else say something else. And I go, Well, that's not really that valuable at all in this situation. But I say why it's well meaning. And so then the person's frazzled, to the point where they thought to reach out into the world to strangers, right. And now these strangers are throwing 20 ideas at them. None of them are cohesive, even if they're good. And so I just couldn't take it. And I, I stepped in and I said, if you want to message me, I'll see if I can help you with this. And there were very kind people who all jumped on and said, I would mesh it, Scott if I was you. So we got we got on the phone. And 45 minutes later, we got off the phone. And the next morning, he sent me his steady overnight graph. And to that day, he sent me his 30 day graph, and the next day, and the next day. And my point is, I can't talk to all of you on the phone and Jenny can't speak personally. But I think we can give you enough tools to get you to that spot. So so keep going with the with this series. And I think you're gonna be happy that you did. I hope you're enjoying the series, I want to take a moment to thank the sponsors dancing for diabetes, real good foods. And even though they weren't mentioned in this episode decks comment on the pod. There are links in your show notes, and at Juicebox podcast.com to all of the sponsors. But you can always go to dancing the number four diabetes.com real good foods.com use the offer code juicebox dexcom.com, slash juicebox. Or my omnipod.com slash juice box to find out more. And don't forget that Jenny does this for a living. And you can find out more about her services at integrated diabetes calm. This episode with Jenny Smith is of course part of a series if you missed the first two, there was diabetes pro tip newly diagnosed you're starting over and diabetes pro tip all about MDI. This, of course, was diabetes pro tip all about insulin. Now if you enjoy these episodes and found them useful, please go to iTunes and leave a rating and review. Over the next few weeks, you'll get the same interview style episodes that you've come to enjoy. And then towards the end of the month, three more episodes coming your way. All About bolusing basal rates pumping glucose monitoring the next steps in this bigger picture. And when Jenny and I finished with these 10 episodes, it's our goal for them to be a roadmap sort of a blueprint for how to use insulin and manage day to day with type one. I also imagine that there may be times during conversational episodes where you hear an idea brought up and you may be able to come back to these episodes for you know a refresher on the concept. Thank you very much for listening to the Juicebox Podcast. I'll see you next week.

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#211 Diabetes Pro Tip: All About MDI

Scott and Jenny Smith, CDE share insights on type 1 diabetes care.….

I am thrilled to welcome Jenny Smith, CDE back to the show. Jenny will be joining us for an extended series of conversations that focus solely on the management ideas that we discuss on the podcast.

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:06
Welcome to the Juicebox Podcast. I'm your host, Scott Benner. And you're listening to the second installment of my series with CDE Jenny Smith. This episode titled all about MDI is just that it's a conversation about multiple daily injections. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, and to always consult a physician before making changes to your medical plan, becoming bold with insulin.

How frequently does someone leave a diagnosis with an insulin pump?

Jennifer Smith, CDE 0:50
I would say never.

Scott Benner 0:55
Johnny Smith has lived with Type One Diabetes since she was a child. She holds a bachelor's degree in human nutrition and biology from the University of Wisconsin. She's also a registered and licensed dietitian, a certified diabetes educator, and a certified trainer on most makes and models of insulin pumps, continuous glucose monitors, and continuous glucose monitors. And besides that, I just really like the way she talks about type one. Jenny Smith is a CD. But she's also a consultant at integrated diabetes, where she helps people who are struggling to figure out their type one, you can find out more about what she does at integrated diabetes.com.

Jennifer Smith, CDE 1:37
Part of the reason for that not leaving a hospitalization or a doctor's office with a pump is because of all of the red tape that you have to sort of go through for ordering and you know, that kind of stuff. I would say the rare case, this is probably 10% of the time, maybe even less, somebody's pretty quick to get the order written by their prescriber. And in fact, I worked with somebody maybe a month ago that her little boy was diagnosed and how to pump within about six weeks. Okay, but that's pretty quick. It's not typically that fast. And

Scott Benner 2:14
most people are going to get diagnosed with Type One Diabetes and leave with either pens, or syringes or syringes, right, yeah. And so whether you are a person who thinks right away, I have to have a pump and you hammer through insurance and get it six weeks later. Or if you're a person who gets told, we don't give pumps to people until you've had diabetes for six months, or any of those arbitrary times that doctors throughout one year

Jennifer Smith, CDE 2:36
or until you're in perfect control, then you can have a pump.

Scott Benner 2:40
You know how to do this so well that you'll never want a pump, we'd be happy to give you one, which will never come. And so some people are going to need to know what managing with just MDI looks like. So multiple daily injections. These people are going to get some sort of a fast acting insulin that they can use it meal times and to try to adjust highs and they're going to get a slow acting insulin, that's going to be their basal insulin. Right, though, so let's start slow with the basal insulin. There's a lot of them on the market at this point. Back when Arden did MDI we were using 11 mir. And we found that we had to split it half a dose every 12 hours. How? How much of that is really good advice about slow acting basal insulin,

Jennifer Smith, CDE 3:28
specifically, that what you found with 11 year as a specific brand or type is very common.

Scott Benner 3:36
Okay? While while you know, the makers of love of beer will say that it is a 24 hour acting insulin. What we find, especially with the smaller doses, is that dosing twice a day or two injections of it works much more optimally because it doesn't carry a full 24 hours. That was absolutely my finding. I think a lot of people find that. So that's the first thing to understand. If you say to yourself, every day is certain time my blood sugar goes up. And I can't understand why I bet you it's about 18 to 20 hours after you've injected your long slow acting insulin. And so the important thing to remember when you if when you make the decision to split your basal insulin is that it might not be a 5050 split. So right say you have your five units or a one unit, it doesn't matter. It doesn't mean you're going to put in a half a unit and then a half unit again, 12 hours later, it might end up being three quarters of a unit or one and then a half later, there's your because your body has different needs at different times.

Jennifer Smith, CDE 4:40
Right. And that kind of goes into understanding the needs of the different age groups. kids and teens tend to have a much more profound increase insulin need in the overnight like literally like as soon as their head hits the pillow kind of thing and through and into the overnight. So splitting dose for, you know, multiple daily injections with the basal insulin, you may have a heavier dose in the evening than you do with that morning time, the heavy dose in the evening carries you through the increase in need overnight as well as the morning which is a little bit higher resistance as well. And then your dose in the morning kind of carries you through the day when you're more active, right? And you likely will need a lower bazel amount.

Scott Benner 5:26
And so all we've really said here, and I I repeat this a lot to people is that setting up your slow acting baseline so when you're on MDI is about amount and timing, right, yeah. We're gonna say this in the next episode, but so make sure you get to that next episode, but you have to balance the impact of the insulin against the action of carbs or body function, right. So it's just, it's about a tug of war between those things. And that again, I'll talk about a little later.

Jennifer Smith, CDE 6:00
And that's we're watching you know, glucose values, especially if you are privy to getting a CGM early on, which I do encourage over I've said it a million times to people that I work with, if I had to decide on a technology piece

Unknown Speaker 6:14
between CGM and a pump. If somebody was going to take one away, I would 100% keep my CGM, right 100% take my pump, I'll figure out my multiple daily injections. As long as I've got the data and the trend of what's happening. I can figure it out. If you were gonna I would 100% agree with you if you're going to say that one thing's more important than the other, which I think is a bit of a, you know, yeah, you're right. I I'm not looking to give one of them away. Well, they're my way Endymion. When you when you lose your pump, when you're using MDI, what what that means is that if you want that kind of like, tighter control, I guess, you're going to be injecting more. If that doesn't bother you, then right on, you know, like, that's absolutely fine.

Jennifer Smith, CDE 6:56
You also actually what my friend ginger does. Ginger Vieira, who I wrote the book with the pregnancy book, which, you know, she long term has been multiple daily injections. She uses CGM, she is not scared to give 12 1620 micro dosing adjustments through the course of the day to keep things tightly managed.

Scott Benner 7:19
And so and i think so I always say the same thing. Here's what you gain with a pump. You don't have to inject all the time. And you now have the ability to manipulate your basal insulin. Yeah, but other than that, there's no more

Jennifer Smith, CDE 7:31
precisely right, we can manipulate bazel with injected bazel. We don't, we don't recommend it. Like we would on a pump, it's difficult to difficult, it's difficult to manipulate. But you can use your precision to do that on a pump. Yeah,

Scott Benner 7:48
the first time I thought about getting on a pump, and I didn't know anything about them, and I went to a pump class at our children's hospital. You know, even back then I didn't realize that, that my basal insulin would just be fast acting insulin given by the pump, but in smaller doses, like, like spread out over minutes and hours, right. And I didn't, I didn't think about that. It was explained to me in that room. And then I thought I could shut it off. Like because how many times I thought, Oh, I wish this level Mir had an off switch right now. Right? Turn it off, she's stable, and she's at but I know she's gonna go down because this, this level here, she's gonna keep working in the

Jennifer Smith, CDE 8:25
bank. And I don't want to feed her three juice boxes just to prevent it right looking for that.

Scott Benner 8:30
I have become adept at manipulating Arden's blood sugar with basal insulin through her pump, but that's not what we're talking about right now. But we'll get to it in a different

Jennifer Smith, CDE 8:39
kind of leaves in it goes very well with MBI because you can manipulate differently even if you are on MDI.

Scott Benner 8:48
And so so I guess the first thing I would just very basic ideas you're injecting you need to pick multiple sites keep rotating your site you can put in so on and over and over in the same spots it's it's incredibly important because you your your spot, your spots will become saturated, you can actually what do they call that when that when you can actually see like bumps under this under your skin from

Jennifer Smith, CDE 9:11
Yeah, it's it's really a either a scar tissue development or potentially fatty tissue under the skin that that light, light bow hypertrophy. Other big, you know, fancy words for it. But really, it's just when you inject in the same place over and over and over and over again, you're damaging the underlying skin tissue. And it can lead to like I said, either scar tissue or fatty deposits, and unfortunately, then the absorption in those areas, is quite variable, quite variable, if anything at all,

Scott Benner 9:46
and you could lose your favorite place and never be able to use it again and walk away. So when your doctor or your nurse practitioner tries to scare you with whatever gin, whatever Jenny just said, they're like, something like that just thinking of myself. Just think to yourself, Well, that sounds scary. what she meant was rotate your sights,

Jennifer Smith, CDE 10:02
rotate your sights, and there, you know, there's so many places on the body to use. I mean, the backs of the arms, the lower back the upper, but the legs, the tongue, the tummy, the sides of your tummy. I mean, you've got a lot of places to use. So I think with little kids,

Scott Benner 10:19
that's always a it's a question with parents, you know, mainly because little kids, there's, there's so little, I mean, Arden was too, right. So it's, it's like it's finding the place on such a little body. And I'm let me veer off for a second to say something that I think people will find valuable, especially parents. I did some quick math, and in the time between art and being diagnosed, just after her second birthday, and when we got her on an omni pod, when she was about four and a half, I think we ejected or, you know, or stuck her fingers a combination of 10 to 15,000 times those years, right? Or a lot. And every time broke my heart in a way that I find difficult to put into words. and years and years later, we had been on the on the pod for years, before we ever ran into a situation where I thought I should inject here just to see if my site is bad, right? So we had had, we were on a just a really great run with with insulin pump sites. But one day, a number of years after we switched from from MDI. I said to Arden, hey, I'm not sure if this site's bad, and I don't want to change the pump if I don't have to. So um, you know, in Jackson, and so on, if it starts going down right away, I'm gonna say the pumps, sights bad. And if it doesn't, then you're just resistant for some reason, we're gonna give you more insulin. So I put it up on the counter. There she is, you know, she's like, six, seven years old. I pull out the insulin, and she's just going along. And I bring out the syringe and she says, What is that? And I was like, it's a syringe. It's a needle, I'm gonna put the insulin and then she goes in then what? And I said, Well, I was thinking of injected. And she was like, Well, well, well, well, well, wait a minute. Like really? Like, what are you doing? I'm not getting a needle. That's not something I do. And I was like, do you not remember these? No idea. no recollection of ever getting a shot ever. So I know, it breaks your heart as a parent. But I don't want to say kids are resilient, but time has a way of, you know, blurring the past. So yeah,

Jennifer Smith, CDE 12:27
absolutely. Absolutely. And that's, you know, even pump sites then, you know, same thing with rotation. Yeah, yeah, they all need to be rotated. And that becomes a, I think it as an as an omni pod. Plus, there are so many more places that you can put that pod. And easier, especially from the kid standpoint, or anybody who has dexterity issues or whatnot. You know, because there's no tubing, there's no tubing, and you can pop it on. And that's even easier than an injection.

Scott Benner 12:59
I've seen people put them backs of arms. Arden wears hers, you know, the left of the right of her navel on her stomach, and you can even and she wears them on her thighs. You can even rotate within a rotation. So you could put it on your stomach canula facing your belly button and then the next day turn it and you know, put it the other way like you can. If you have four spots, you have 20 you know maybe because you can just kind of start moving around a little bit. I've grown grown women who wear them on their breasts like that one. Like I show that every once in a while somebody will kind of like pull their shirt down online. I said it's the Arden arms like I've never done that though. Yeah,

Jennifer Smith, CDE 13:37
yeah. I've not tried that myself. Although, you know, this year, Chris Freeman.

Scott Benner 13:43
I was gonna bring Chris on.

Jennifer Smith, CDE 13:45
He wears he wears it on his chest. Yeah. And I know he also wears it on like his upper back. And I've seen people on many of the like the Facebook, diabetes groups and whatnot. The places that I mean, people wear them on their calf. I've seen people wearing them on their forearm. Now, although not approved site. Again, this is where your diabetes will vary. And you figure out what works for you. But you know, yeah,

Scott Benner 14:13
for people who don't know Chris is a four time Olympian and a cross country skier. And there is a picture that he shared years ago that is to this date, the most popular thing I've ever put on my website. So ladies, you might want to look at why you're clicking on things, but it's Chris without his shirt on. And he has no body fat to speak no, because we're the reason he wears it where he does and my point is he still pumping and using a dexcom and so if someone tells you you're too skinny for this, or I've heard it both ways, so funny. Oh, you're too your kids too chubby for that pump. Your kids too skinny for that pump. I there have been I've heard a million different excuses. But okay, so MDI, so rotate our sites. What are other good practice? is around MBI.

Jennifer Smith, CDE 15:01
Other really good practices, make sure you are changing the syringe, if you're using a pen, really, really important as syringe itself, as well as the pen needle caps. In fact, one of the very, very common practice for people to do is reuse the pen cap. And by reusing, they actually store the insulin pen with the needle cap, screwed on to the pen. Really not a good idea, it can introduce air into the pen. And it can change the way that the pen dialing and actually dose the insulin. So if you are going to reuse the needle cap, I don't recommend doing it. But if you are going to do it, take the needle cap off in between those uses. Always make sure that you're wiping the top of the needle, or the insulin pen itself, you know, with an alcohol swab, just cleanliness. Those are kind of the basics.

Scott Benner 16:01
Okay, well, what about and I realized to go back for a second, you were starting by saying don't reuse a syringe, which never in my wildest dreams even occurred to me, but you're telling me people do that, too.

Jennifer Smith, CDE 16:10
People do that. Absolutely. And, you know, having worked with people across the spectrum of economic setting, just like insulin is expensive. I mean, even though a box of syringes is not expensive, even off of the shelf, it's not expensive without a prescription. Again, it may be something that people are reusing because it's an expense that they could decrease somewhere, right? You know, so if you

Scott Benner 16:40
could avoid that, please do. So I have a question. And here's a good place to put it. I'm probably gonna bring it up again, we talked about pumping. So the quickest story would be that one day I took off Arden's pump, and I saw a little redness under where the adhesive was. And I was quite literally standing in my house, rubbing my hands together thinking, because I was scared Oh my God, is she allergic to this adhesive, and we can't pump any more like my brain was racing. And I'm rubbing my hands together and rub my hands together. And as I was doing, and I thought, Why are my hands so dry? And then I realized I'm constantly touching alcohol. Yeah. And so I do a little research and I find out that in Europe, it is not common practice to clean anything, a site with alcohol. And I was like, Huh, so I stopped doing that. And Ardennes never had that problem again, and my hands don't crack as much in the wintertime. And so is that a lawsuit? decision? Like do you say to somebody clean this with alcohol first, because every once in a while someone's gonna get an infection or why do we teach it and some other places don't.

Jennifer Smith, CDE 17:53
Alcohol itself is not a I guess the best thing that that I can call in layman's terms, it's a degreaser. It literally wipes clean, that area of any freeze any any skin moisture, any lotions, anything that could be on there. It's not antibacterial, okay, it's wiping the area in Sure, right. But the real reason for cleaning the site is just to make sure that you've you've taken care of anything that could be there and as far as adhesive component, it's very likely of course that the adhesive isn't going to stick as well if you've got body lotion on it or if you haven't taken a bath in two days and you're putting it on your skin and your skin has done its normal thing and you've got oily skin so the adhesive isn't really gonna stick as well. What do I tell people, I also do not use alcohol. Oh my gosh, a CDE that doesn't use alcohol swabs. But I do of course have a clean site. And by clean site I make sure that I wash the area. Soap and water make sure that it's clean dry it and that's what I you know apply on top of then you're entirely 100% right? Alcohol is it will dehydrate the skin and used over and over and over especially for kiddos little kiddos who have very sensitive skin to begin with. You're just asking for more. I mean, there are skin barriers if you do truly have a you know, a site problem. But yeah, even for injections though, making sure that the injection site is just clean. I mean obviously if your kids been outside rolling in the mud or in the sandbox or doing whatever they've been doing in the rain puddle, clean the site,

Unknown Speaker 19:47
jacked into it.

Scott Benner 19:48
Do the same thing. I use warm water, clean towel, a clean towel to dry it, let it air dry, something like that. It goes on, you know, schedule your pod change around your shower, you know Get out of your shower. Sometimes, you know, I see some people like, they call them naked showers where they change all their gear, they take it off before they jump in for free or for a couple minutes, they jump out and they do it, then there's a bunch of different ways to do it. But I think the important thing here is to use your common sense, right like to. And that's all I did that day, I thought I'm drying her skin out, and then throwing this adhesive on top of her. No wonder there's a reaction here. Absolutely. There is a wonderful post on my blog about how to treat real severe adhesive allergies, it is one of the most popular posts over the last five years. And I'll link it in this so that people are great. It was written by a mom who devised a infallible plan. And when you see the pictures of the reaction that her poor kid was having, it was an all over body reaction. And she figured out a way for it not to happen and him to keep using this stuff. So that was really good. I remember the first time Arden was in like a thin pair of like yoga pants as like a four year old, and or a three year old or four year old and I wanted to give her a shot in her leg. But we were out and I just was like, I'm just gonna jab the knee right through the pants. And that's what I was like, okay, maybe all these rules aren't that important. And and you know, and so she was like, Oh, my God, what are you doing? And I said, No, it's fine. I brought it up in you know, now I say I've done that in the past and she was mortified. She's like, why would you? I was like, Listen, we were in the mall, you know, like, like, what do you want me to? Because I and here's something I really believe. And I think this is a great place to bring it up. I don't think you should hide when you give yourself injections. No, I agree. I think that not just not hiding. But why in a public place? Would you go to what is arguably the dirtiest, the bathroom to write up a hole into your body?

Jennifer Smith, CDE 21:56
Absolutely. kind of goes along with nursing for women. Why should you have to go to the bathroom to nurse when it's the same thing. It's the comfort level of other people. It's not your comfort level that you're worried about.

Scott Benner 22:13
The Dexcom g six CGM is now FDA permitted for zero finger sticks. That's right, the continuous glucose monitor that Arden has been using forever, does not require calibration from a blood glucose meter any longer. But do you know what it does do? It allows you to see your blood sugar, speed and direction. Are you rising at two points a minute falling at three points a minute, the dexcom CGM will let you know with customizable alerts. And if you're the caregiver or someone who loves someone with type one diabetes, and you'd like to be able to see their blood sugar when they're not with you, that's possible too. Because Dexcom has a share and follow feature that is available for Apple and Android. My daughter's in school right now. We just gave her insulin for her lunch, and I can see her blood sugar. Her blood sugar started to creep up on us a little bit. So I got an alert and we added some insulin stopping arise. The dexcom g six features an applicator that is virtually painless. My daughter says she can't feel it at all. And it's completely automatic. One button push and the sensor bed has been applied. You snap in the transmitter and you're on your way. You can see your blood sugar's on your Apple watch or other smartwatches on your iPhone on your Android phone. You can share it with anyone in the world anywhere. I can tell you without hesitation that the Dexcom continuous glucose monitor is without a doubt one of the main reasons why we've been able to keep my daughter's a one c between 5.2 and 6.2 for five continuous years. To find out more go to dexcom.com forward slash juice box or the links in your podcast player show notes or at Juicebox podcast.com. It's going to be the best decision that you ever made. In 2008, we made the decision to get my then four year old daughter an insulin pump. It's a decision that I wish we would have made years sooner. After seeing everything that was available. We easily settled on the Omni pod that was back again in 2008. Today Arden is about to turn 15 years old and she has been wearing it on the pod every day since then, every day. And as I mentioned in the other ad, Arden z one z has been between 5.2 and 6.2 for five solid years. How do we do that? Well, we start by seeing an insulin pump is more than just a way to not have to take shots. The Omni pod gives you the ability to do temporary basal rates, that's increases or decreases in your background insulin, extended boluses which will help you spread out your insulin over the life of a meal and so much more. The Omni pod has no tubing at all. The pod is self contained. You wear it on your body You control it with a wireless controller. So there's no tubes running through your clothing, and no pump that you have to jam in your bra or down your pants or wherever people have to put their palms that just doesn't exist with the Omni pod. What does exist is the ability to swim while you're getting your insulin bathed while you're getting your insulin and live life untethered. The Omni pod even features self insertion, just push a button. Now I want you to go to my Omni pod.com forward slash juice box. And when you get there, you'll get a free, no obligation demonstration pod sent directly to your house. Check it out and see what you think for yourself.

Jennifer Smith, CDE 25:46
It's the comfort level of other people. It's not your comfort level that you're worried about. Exactly.

Scott Benner 25:51
And so let me tell you, the briefest story. I'm in a restaurant one day with my kids. Were leaving that day. And there's this little girl seriously a little girl injecting at her table. And I stopped at the table, none of my business. I said, Excuse me. I just want to do it. May I say something and they looked up at me in horror, I realized now and I said, My daughter has type one diabetes too. And I want to say good for you for injecting here at the table. There's no reason for you to hide. You're doing a great job, little girl. Last year, I got to do the math. Last year, seven years later, I had to make a phone call about jury duty. And I said, Look, I would like to skip jury duty because I'm the sole caregiver for my daughter, I help her make her insulin decisions. And if you listen, if you'll let me be on my phone while I'm there, I don't care. But if you don't want me on my phone, I need to ask the skip. Right. And the woman says oh, I completely understand. My daughter has type one diabetes too. And I gave her my name. And she says is your daughter's name Arden and I was freaked out. And I thought Yeah, why? And she goes, I read your blog. And I said great. She goes, actually you're gonna find this strange. You've been a real help to my daughter through her life. And I said why? And she said, because you bumped into us in a restaurant, the week a week she was diagnosed, and you told her she was doing a good job and she shouldn't hide. And she's like, and it's been such a big deal in her life. And I was like, wow, oh, touching. I'm gonna get out of jury duty. Right? And, but, but absolute 100% honest story. Like Don't, don't hide, you know, and because Jenny's right it is for other people. It's not for you, and it quietly you'll you feel shame like it quietly will make you feel shameful about what you're doing and you should not be ashamed of accounting type on

Jennifer Smith, CDE 27:50
that at all. It's just like, you know, I mean, everybody wears it I mean, it kind of goes along with everybody wears their pump differently. And there are a lot of people especially Omnipod wares who wear them you know, only in like, unseen locations. Man I like I wouldn't bipod there get decorated with stickers and I used to like color them with markers and now that now that you know we have the 3d printer kind of thing. We don't but I ordered a Wonder Woman 3d print pack snaps. It snaps over the top. It's awesome. I actually got my six year old pick it out because he was like, wow, all those are cool. You have to get Wonder Woman mommy are wonderful. I was like great. I missed that one.

Scott Benner 28:38
But mommy was ours but okay.

Jennifer Smith, CDE 28:41
In fact, one of my favorite places to wear it is on the back of my arm because honestly because it isn't visible. Yeah, not like the other places on my body aren't good. It's just I like to wear it good spot visibly, you know,

Scott Benner 28:54
I would tell you that Arden has in the past seen other people using insulin pumps on the pod and CGM. And it she's not the kind of person who runs around excited about it, but it has quietly given her a lot of comfort. Yeah,

Jennifer Smith, CDE 29:08
yeah. It's always fun to when you run into I call it diabetes in the wild. Like you run into somebody at the grocery store who's like, you know, boldly got their pump, like hanging off their pants or, you know, clip to their jacket or you know, something like that, because I I always reach out I'm always like, Hey, you know, look, you

Scott Benner 29:26
pumps we've all got pumps, and it kind of starts up a conversation and it's, I don't know it just because diabetes is so like, it's such a silent on scene. For the most part. It's just a nice way to bring it to a visible and make it make it normal because when and here's why that's important. I interviewed a singer A long time ago, a Broadway singer named Kelly. And if you go back and listen to Kelly's episode, which I'll link in the show notes, she hid for a long, long time. And it was not good for her. When she finally decided not to do that it was freeing. So I'm saying don't put yourself in a position to begin with, you know, just be yourself and write and this is who you are. And look, I'm not judging you, if you can't bring yourself to do it in public. I'm not saying. But I'm saying if you can do it, do it, you know, you'll be happy with what happens. So, okay, so what are we not? I haven't, I haven't injected insulin in a really long time. So let me tell you one thing that happens to me all the time, every once in a while when I have to give a needle I'm not good at it. tells me I'm not good at it. And so what, what is, like, what should I be doing? Is there a pinch? Is it quick? Is it slow? Like, what's the right way to stick that needle in there?

Jennifer Smith, CDE 30:49
Do it? Yeah, I mean, you know, obviously, the age old recommendation is to pinch up. To put the needle in, when I was initially diagnosed 30 years ago, we were told to inject at an angle almost at like a 45 degree angle. Quite honestly, now the the recommendation is just like most 90 degree pump sets, just straight up, putting it straight in, no angle is needed. A lot of people have questioned to about the needle length, and all of the research and studies that have been done. Regardless of body type, and body stop body size. Even those really, really micro looking needle lengths, they give you the same, the same ability to put the insulin under the skin in the place that it needs to be, which is the sub q tissue, like the that kind of fatty layer for absorption. So pinching up the skin, putting the syringe or the the needle that's on the the pen straight in 90 degree angle, and then just push the insulin in,

Scott Benner 31:59
that I have to keep the needle in for a second or is that a pen thing?

Jennifer Smith, CDE 32:02
That's for the pen. Really, the recommendation is it does vary. I've heard people being told that they're supposed to count to 20. I've heard people say that they're supposed to count to five. When I was initially educated, we were told to tell people count to 10. So that is what I educate with. And it's interesting because if you have ever given a syringe injection versus a pen injection, you will notice the difference if you pull that pen needle out right after and you don't give that count to 10, some of the influent can leak out. Okay. So that's the reason for that count. And whether it's a basal insulin or your rapid acting insulin or a regular insulin. If it's a pen, you do need to do that count.

Scott Benner 32:49
Okay. All right. Um, let's see what you think of anything that I'm not asking you about because I'm at a disadvantage when talking about MDI.

Jennifer Smith, CDE 32:57
I mean, the only I mean, we kind of, you know, bazel insulin, of course, rapid acting insulin, you know, there are multiple of them on the market. And there also is still some use of regular insulin which we called short acting insulin, it had a longer profile of of working in the body than our rapid acting insulins have, it also didn't work as fast. So again, this is where figuring out what your needs might be. For the most part, the rapid insulins on the market, the three age old ones, you know, human log novolog, a Piedra, technically, they're all supposed to work pretty much the same way I can tell you my personal and have one is that human log and Nova log work pretty much the same for me, a Piedra does not I've tried it, it doesn't work the same for me. Then there's also of course, Vf, which is faster acting insulin aspart, which is just faster acting novolog insolence. It does have a faster onset of action, and has, in my experience, having used it for a bit of time, it seemed to have almost a more clean finish to working. It was done and and that was kind of the end of its actual in my bazel was kind of kicking in and doing what it was supposed to do. But you know, determining what again, works for you insurance wise, many insurance plans have a preferred or a tiered kind of both bazel and rapid acting insulin for you to choose. monetarily, if you can go outside of you know, tier one or tier two, most influence are tier two. If you can go outside of that, they'll usually be a tier three and your copay is just going to be more. But if you prefer one over the other, that might be the course of action you have to do. If you can't, then you're kind of stuck using what the preferred is

Scott Benner 34:52
okay? And I'm gonna ask you one question and then we're gonna switch to another episode and talk about insulin. So the one thing I've found That when I talk about Pre-Bolus with people, and you know Pre-Bolus thing is a pumping word, it just means putting your insulin in before your food, right. So you can, you can pre inject you call it whatever you want. But but some, but a lot of times what you'll hear from especially parents is I don't want to inject them twice at a meal time. And I say, look, I understand that, but but if you can't be sure of how much insulin, how much food the child is going to eat, you still need to get some moving first. So if you're on MDI, and you're seeing crazy spikes at your meals, it's because you're not Pre-Bolus thing, I'm guessing, or a lot of other reasons that you'll hear through the next bunch of episodes. But you're gonna have to make that leap in your head like I'm gonna, if I can't trust he's gonna eat all this or she's gonna eat all this, then I need to put some in now, and summon later,

Unknown Speaker 35:49
right.

Scott Benner 35:52
Please remember that the Juicebox Podcast wouldn't be possible without its sponsors for today's episode on the pod, and Dexcom Dexcom, the makers of the G six continuous glucose monitor, and of course on the pod is the tubeless insulin pump that Arden has been wearing for over a decade. You can go to my Omni pod.com forward slash juice box to get a free no obligation demo of the pump sent right to your house. Or you can go to dexcom.com. forward slash juice box to find out more about art in CGM. Heck, you could do both. The next episode of my series with Jenny Smith is called all about insulin. And it's available now at Juicebox podcast.com. are right there in your podcast app. If you're enjoying the podcast, please leave a rating and review on iTunes and take a moment to share the show with someone who you think it can help. Thank you for listening for being bold with insulin, and for remembering that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise. And to always consult a physician before making any changes to your health care plan.

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